CAREGIVER INFORMATION FORM
Child’s Name: ______
Case No.: Date of Birth:
Name of Caregiver: ______
Type of Caregiver:
q Foster Parent
q Kinship Caregiver
q Other (Please specify):______
Date of Child’s Placement with you: ______
Juvenile Court Number: ______
Date of this Report: ______
Under Ohio law, foster and kinship caregivers have the right to attend and be heard in court proceedings related to the children in their care. This form is intended to help you provide information to the court at the next hearing related to the child in your care. Please answer questions below that are relevant to the child’s current status and needs. You can also obtain a fillable form online at ______. Once you have completed the online form, please print and bring or mail to the court.
You do not need to answer all questions. Use of this form is voluntary.
1. Have you received a copy of the most recent case plan? (circle one) Yes No
2. Is there anything you would suggest be added to the case plan?
3. Please describe any behavioral, emotional, or mental health concerns with the child, if any exist (for example, any changes in eating or sleeping patterns, acting out or aggressive behaviors, withdrawal, etc.). Are any such concerns being addressed with services?
4. Please identify any needs this child has that are not currently being addressed with services.
5. Please describe the child’s educational progress and identify any concerns (for example, peer or teacher issues, bullying, academic progress or lack of progress, special education needs).
6. If age appropriate, what independent living services have been provided? What age-appropriate tasks and skills have you provided to the child to assist them in preparing for independence (e.g. cooking, cleaning, finances)? Are there such services you would recommend?
7. Please describe your observations of the child’s interactions with other children and adults.
8. Has this child received any medical or dental treatment since the last hearing? Please describe.
9. Please note your observations related to child’s contacts and visits with his or her birth parents.
10. Does the child have regular, ongoing opportunities to socialize or participate in recreational activities with peers? If so, please describe. Please include any challenges to participation in activities.
11. Are there any additional services or supports needed for the child or for you that were not previously mentioned?
12. Has a guardian ad litem or Court Appointed Special Advocate (CASA) been appointed for the child/youth? If so, what was the date and location of the last contact?
13. Have you been made aware of the most recent report and/or recommendations by the Guardian ad Litem (GAL) or Court Appointed Special Advocate (CASA) in this case? If so, do you agree with the recommendations? If you do not agree with the recommendations, what recommendations would you make? Are there any additional recommendations you would make?
14. Have you been made aware of the most recent report(s) and/or recommendations in this case made by persons other than the GAL or CASA? If so, do you agree with the report(s) and/or recommendations? If you do not agree with the report or recommendations, please explain. Are there any additional recommendations you would make?
15. If the child/youth is in the permanent custody of the public children services agency (PCSA), please describe any efforts of which you are aware to locate a permanent adoptive family or kinship placement.
16. General progress, comments, or recommendations regarding the child/youth:
______
Caregiver Signature Date
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